HomeMy WebLinkAboutBLDG-21-001586 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
lk,,, _ .,, CITY YARMOUTH MA DATE September 25,202 PERMIT# BLDG-21-001586
1.
JOBSITE ADDRESS 46 PLEASANT ST OWNER'S NAME REILLY JAMES J
G OWNER ADDRESS C/O J MCLELLAN P 0 BOX 372 SO EASTON MA 02375 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO El
FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS _
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
• UNVENTED ROOM HEATER
WATER HEATER 1
OTHER
OTHER DESCRIPTION:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY El BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts
General Laws,and that my signature on this permit application waives this requirement.
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Andrew Cameron LICENSE# 31643 SIGNATURE
MP❑ MGF El JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: ANDREW J CAMERON ADDRESS. 1 FITZGIBBONS LN,
CITY ROCKLAND STATE MA ZIP 023701968 TEL
FAX 1 I CELL EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE:$ PERMIT#
PLAN REVIEW NOTES
•
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'• MA DATE 9//7/0 2-0 PERMIT#
JOBSITE ADDRESS y6 P‘i,ssrN/ cS OWNERS NAME
GOWNER ADDRESS 76 ' /43 f S - TEI ' )) 9,c- 86917 FAX
,
TYPET OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALk
PRIT
CLEARLY NEW:❑ RENOVATION:k REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-4 BSM 1 2 3 11 5 6 7 s 9 10 111 12 13 14
BOILER _ 1
l
BOOSTER ----I
CONVERSION BURNER
COOK STOVE i
DIRECT VENT HEATER
DRYER I
FIREPLACE , L
I
FRYOLATOR
FURNACE
GENERATOR.
GRILLE I
INFRARED HEATER
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN L__
POOL HEATER •
ROOM I SPACE HEATER
ROOF TOP UNIT ,
TEST . . . .... . -- -• --
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER __ _
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 110 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY tli---_ OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
� Massachusetts General Laws,and that my signature on this permit application waives this requirement.
. CHECK ONE ONLY: OWNER ❑ AGENT ❑
J SIGNATURE OF OWNER OR AGENT
ri•• I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
` and that all plumbing work and installations performed under the permit issued for this application will be in compiianc with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Lo
PLUMBER-GASFITTER NAME LICENSE# 314 Lo SIGNATURE
MP ❑ MGF❑ JP gi JGF
❑ LPGI ❑ CORPORATION❑it PARTNERSHIP❑# LLC❑#
COMPANY NAME C^�n`L VM U1 ADDRESS / F 'b4vr•- L A' -
CITY 0 e 0( STATE A ZIP 6 23 7° TEI(6 i) 3 V7- &Vol
FAX CELA/?), 3q/7 —59O/ EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
/6- Qk- 9 iss 1 z°' Cam. Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑
FEE: $ PERMIT ft
PLAN REVIEW NOTES
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